02120066 (2) CITY OF CUPERTINO '• •" �" `' ""
BUILDING DIVISION PERMIT CONTRACTORnINFORMATION �-
BUILDING ADDRESS: A PERFECT CLIMATE PERMIT NO.
10168 COLBY AV02120066
OWNER'S NAME: 10570 S DEANZA BLVD APPLICATION SUB DATE
VARSHA JOSHI — 12/16/2002
IONI:: 4O8 861-9545 SANITARY NO. CONTROL.NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
woo LICENS17D CONTRACT'OR'S DECLARATION
P I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Inas with Section 7gX11of Division Sof HC Business and Profexshms COticund my licensom
i�Cl
NEW FURNACE �'~ = L' HALE®
OZ— Com 'orCc AN
S:0 rued as pre he r«rims DEC 2 Ir 2002
xOaU
m 3 u.u Licensed Professional
k'apa OWNER-BUILDIiR DECLARATION
t- I hereby affirm that 1 am cxcmPt from the Contractors License Law for the
al
a °o following masom (Section 7031.5.Business and Professions Code.Any cityor county BUILDING
which requires a Permit to construct,alter,improve,demolish.Or repair any structure
Prior to its issuance,also requires the 3PPIIemft for such Perrino file a signed statement
fiGthat he is licensed pursuant to the provisions of the Contractor's Liwmc Law(Chapter 9 Sq. Ft, Floor Area $21S`8 aatlon
(commencing with Section 7(XXB of Division 3 or the Business and Professions Cmlq of
a 3$ Thal he is exempt therefrom and Ne basis for he alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
not more Nan five hundred dollars($504 bC Occupancy Type
❑I,a owner of the proper y,Or my employees with wages as their sole compensation,
will do Ne work,and the strucmrt is not intended or offered for sale(Sec.70,1q Business 3 .
and Profession Code:The Comnnor's License Law does not apply m an owner of 3 03 — ROUGH CLllOnS
pmperty who buildsor improves Hereon,and who dres such work himself or Hrough his
own employers.provideo that such improvements sum not intended orofemd for sale,If, .304 — ROUGH ELECTRICAL
however.the building or improvement is sold within one year of completion,the owner- SOS — FINAL ELECTRICAL
bild
uer will have the burden of proving that he did not build or improve for purpose of
stake.). 507 — FINAL PLUMBING
❑I,as owner of the progeny,am exclusively contracting with licensed convenors to 508 — FINAL MECHANICAL
comm�ct the prplcet(Sec.70,14.Business and Professions Code:)The Contractor's Li
cense law dres not apply to an owner of pnpcny who Wilds or improves thereon,and
who contracts for such Projects with a contra om s)licensed pursuant to the Contractor's
License Law.
1 am exempt under Sec. ,B&P C for this mason
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
Ihavc anJ will maintaineCenifeste of Conserv hs self-insert for Wmker's Compere
motion,as provided for by Section 37 X)of the labor Code,for the pe formance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurznce,as required by Section
3I00 of flee`CsLabor Code.for Um Performance of the work for which this permit is issued.
My umber
CL,?V CERTIFICATE
OF carrier and PolcPolicynWORK
CERTIFICATEPE SATION'IO WORKERS'
COMPENSATIONINSURANCE
(This section need nut be completed Kate permit is(m ore hundred dollars($10i
Or less.)
I certify that in the performance of the work for which this Permit is issued.1 shall not
employ any pecan in any manner sts at to become subject to the Workeri Compensation
Laws of California.Date
ApPlicem
NOTICE TO APPLICANT:Ir,after making this Cent licate of Exemption,you should
become subject to the Worker's Compensation provisions of the Lahm Code,you must
0 z forthwith comply with such provisions or His N.it shall M deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(-+ Ihereby affirm that Here is a Construction lending agency fns due performance of
Ni Ne work for which this Permit is ismed(Ser.3097.Civ,C.)
D.1 Q Lender's Name
LL I-ender's Address
� z
V 1 eenify that l have read this application and sale that the above information is
correct.)agree to comply with all city and county ordinances and state laws relating to
�U building construction,and heathy amhamm mpomirdiives of this city to enter upon the
erty
purpo
abovetmjudg judgments.
costs
for inspection which may
y (We)agree m save.indemnify and keep harmless the City of Cupertino against
h
liabilities,qencemcnu.nrsuand expenses thisPermit. may in any way amount against said City
U meanseA,T NDERSTANthe grantingDSAsDWIL Issued by. Dale B—
^O APPLICA T UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOU C EG�ILATIONS
,ammApphcand Ontario, Il /� t Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will be applicantmfuture building occupant store or handle li 2WOu material
ass defined by the Cupcnino Municipal Com ,Chapter 9.12,and He Ilcalth and Safety
Code,Serin,n z5532(a)7 All roofs shall be inspected prior to an roofing material beim
Dr°a t=(Nn P P Y B g installed.
Will the applicant or future building Occu t use t m devices which If a roof is installed without first obtaining an inspection, I agree to remove
pan a Air n g p g
mil ice? us air contaminants as defined by IM Bay Arca Air Quality Management all new materials for inspection.
District? 11
❑Vcs Ni,
I have road the himcdom matelots mlionemcn¢ander Chum,695 oft he Culifor-
ria IIea1W&Safety Code Section 25N15.25533 and 2553,1.1 undersand Nat if He hal Wing
dres not currently have a Imam,that it is my responsibility m notify.the Occupant of He
regmmmratsw ith a.",
l`IX
U —met r.ctmfitaten •Signature of Applicant Date
aunrcmO rcJag „
All roof coverings to be Class "B" or better